Progress Report Overview

Student: Brandi Kam

Activity: Gordon Feldman

Start Time: 01/14/2023 21:19:17

End Time: 01/14/2023 21:56:37

Total Time: 00:37:20

Actions

Note at 01/14/2023 21:56:29

Gordon Feldman Documentation
Student: Brandi Kam
Activity Start: 01/14/2023 21:19:17
Activity Completion: 01/14/2023 21:56:37
Activity Completion: 00:37:20

Patient Data

Patient: Gordon Feldman DOB: 10/05/1970

Age/Sex: 52 yo M MR#: MR197263
Location: General Hospital Admit Date: 01/10/2023

Notes

Note at 01/14/2023 21:20:00

Nutrition ADIME Note

Basic Information

Date:

01/14/2023 21:20:00

Author:
Brandi Kam

Location:
General Hospital

Assessment:

The man was well until four days ago when he presented with a one day history of abdominal pain, diarrhea, vomiting, and nausea.
The patient has had an history of hemodialysis, and has been on peritoneal dialysis for now two years. The abdominal pain is not
relieved even with strong anti-pain medications like morphine. He had to miss his last dialysis due to his chronic abdominal pain. CT
scans of the abdomen shows no positive findings. She was put on empiric antibiotic cover for as one of the differentials was
peritonitis. The patient reported to be feeling better on the fifth day of admission.

Admitting dx:

End-stage renal disease (ESRD)

PMH:
HIV disease
Hypertension
End stage renal disease on dialysis
Chronic renal failure
Secondly hyperparathyroidism
Hematuria
Cystitis
Hyperkalemia
Anemia
Diverticulitis of Colon
Postoperative serum

Ht:

188 cm

Wt:

99.7 kg

BMI:

28

IBW:

190

Diet Rx:

Full liquids and oral meds

Nutrition focused physical exam:

Diagnosis Ritonavir food interaction as evidenced by chronic diarrhea and chronic abdominal pain impairing nutrient absorption
causing anemia evidenced by the low hemoglobin levels.
The elevated creatinine and BuN levels are related to the kidney disease.

Relevant meds:

Darunavir Ethanolate [Prezista] 800 mg PO WSUP

Labetalol HCl [Trandate] 200 mg PO DAILY
NIFEdipine [Nifedipine ER] 60 mg PO BID
Abacavir [Ziagen] 300 mg PO BID
Ritonavir [Norvir] 100 mg PO WSUP
Sodium Bicarbonate 667 mg PO TIDAC
Calcium Acetate [Phoslo] 1,334 mg PO TIDWM
Lamivudine [Epivir] 50 mg PO DAILY
B Complex & C No.20/Folic Acid [Renal Caps Softgel] 1 mg PO DAILY
ALPRAZolam [Xanax] 0.25 mg PO BID PRN
Cinacalcet HCl [Sensipar] 60 mg PO DAILY
Paricalcitol [Zemplar] 2 capsule PO DAILY

Relevant labs:
CBC
HGB 11.4 L
HCT 35.4 L
WBC 9.4
PLT 188
RBC 4.19 L
MCV 84.5
MCH 27.3
MCHC 32.3 L
RDW 17.3 H
MVP 8.4

CMP
NA 144
K 5.3 H
CL 109 H
CO2 23
ANION GAP 12
BUN 87 H
CRT 13.8 H
EST GFR (AFRICAN) 5 L
EST GFR (NON-AFRICAN) 4 L
BUN/CRT 6.3 L
CALC OSM 313 H
CA 9.5
TOT BILI 0.3
AST 27
ALT 18
C-REACTIVE PROTEIN <0.5
TOTAL PROTEIN 7.4
ALBUMIN 4.0
GLOBULIN 3.4
HCO3 23
GLUCOSE 84

Estimated Nutrition Requirements

Kcal:

2492.5-2991 kcals

Protein:

103.2 - 129 grams per day

Diagnosis (nutrition):

Altered nutrition-related lab values related to acute kidney injury AB increased BUN and creatinine.

Nutrition goal(s):
Currently patient on full liquid diet. Advance renal diet with modified protein restriction of 103.2 - 129 grams per day and 2492.5-
2991kcal calorie diet.

Intervention

Recommendation:

The recommended would be 25-30 kcals/kg

The caloric needs would be 2492.5-2991 kcals.
The patient is obese and may need to make some caloric adjustments.
The caloric adjustments will be subject to the achievement of the ideal body weight after which the normal recommended
range will be adopted
The recommended protein range is 1.2-1.5 g/kg. The patient is undergoing peritonel dialysis and may need protein restriction.

Collaboration of care:

Appropriate amounts of macro- and micro-nutrients with particular emphasis on vitamin B12, iron, and folate.

Monitor/evaluate:

Follow up to monitor the progression of the symptoms. Check weights and labs.